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Isolation multiple choice Read Mike Jackson’s Guidelines on how to


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Doppler ultrasound

Isolation precautions to prevent


the spread of contagious diseases
NS478 Gould D (2009) Isolation precautions to prevent the spread of contagious diseases.
Nursing Standard. 23, 22, 47-55. Date of acceptance: October 17 2008.

Aims and intended learning outcomes


Summary
This article explores the use of isolation precautions
This article explores the use of isolation precautions to
to prevent the spread of infection. It also outlines
prevent the spread of infection. The standard infection
the standard infection control precautions that must
control precautions, which should be undertaken routinely
be undertaken routinely with every patient and
with all patients, and the additional measures which should
explains the additional measures necessary when a
be adopted when a patient has a specific infection, are
patient has a specific infection. After reading this
discussed. The use of single room accommodation for
article you should be able to:
patients with infections is debated.
Explain the routine precautions that should be
Author
taken to reduce the risk of infection in all
Dinah Gould is professor in applied health, City University, London. patients.
Email: D.Gould@city.ac.uk
Describe the chain of infection and use it to
Keywords identify the risks associated with specific
Communicable diseases; Healthcare-associated microorganisms able to cause disease.
infections; Infection control; Isolation nursing Discuss the main ways infections are spread
These keywords are based on the subject headings from the British in clinical settings.
Nursing Index. This article has been subject to double-blind review. Discuss the use of contact precautions,
For author and research article guidelines visit the Nursing Standard precautions to prevent the spread of infections
home page at nursingstandard.rcnpublishing.co.uk. For related disseminated by respiratory droplets and
articles visit our online archive and search using the keywords. microorganisms spread by the airborne route.
Debate the advantages and disadvantages of
segregation as part of isolation precautions.
CONTAGIOUS DISEASES have inspired
fear since antiquity. Traditionally, people thought to
be carrying infection have been kept apart from the
Historical overview
rest of society. Today, isolation precautions are still
used to prevent the spread of classic communicable Microorganisms were first identified as the cause
diseases, such as tuberculosis and meningococcal of infection at the end of the nineteenth century
meningitis. Isolation precautions are also frequently (Selwyn 1991). The fear of contagious disease,
necessary to prevent the spread of healthcare- however, dates from at least biblical times. People
associated infections (HCAIs), especially those with leprosy and plague were usually segregated
caused by antibiotic-resistant strains of bacteria from the rest of society, a practice which continued
such as meticillin-resistant Staphylococcus aureus into the Middle Ages.
(MRSA) and glycopeptide-resistant enterococci Florence Nightingale was not an advocate of the
(GRE). newly-posed germ theory of infection, but she was
aware that infection was more likely to be

NURSING STANDARD february 4 :: vol 23 no 22 :: 2009 47


about a wide range of different infections. The
learning zone infection control disadvantages are that care is not tailored to meet
the needs of the individual patient or to control a
specific infection. The point of isolation is to
transmitted from contact with bodily fluids than isolate the infectious organism so that it is not
from environmental sources and that risk could be transferred to anyone else. This is not necessarily
reduced by implementing barrier precautions. Early the same thing as isolating the patient. Instead,
in the twentieth century people with assessment of the risk of transmitting infection
infectious conditions were usually isolated in should be integral to each clinical activity.
special fever hospitals, but these gradually closed
with improvements in medical and nursing care. At Today, there is a move away from standard
the same time, the need for isolation in general categories of isolation precautions in favour of care
hospitals increased because of the emergence of customised to meet the needs of the individual. The
antibiotic-resistant strains of bacteria. use of more specific isolation precautions targeted
The earliest commercially available antibiotic, against specific microorganisms is also part of the
penicillin, was first used in clinical practice in the drive towards evidence-based practice (Wilson
UK in the 1940s. Its introduction was rapidly 2006). However, there are times when the nature of
followed by evidence of bacterial resistance to the infection is not known and blanket measures
antimicrobial agents (Trnobranski 1998). must be implemented until a diagnosis has been
established. Moreover, the same standard principles
must be applied routinely with all patients to
Standard versus targeted precautions
prevent the transmission of HCAI and blood-borne
By the 1950s the use of barrier precautions to pathogens (Figure 1).
control the spread of infection had become a
routine part of nursing practice. Standard
categories of isolation were formulated to enable Time out 2
staff to look after patients with a wide range of
different conditions by adopting a broad range Obtain a copy of the most recent national
of precautions listed for each category of infection evidence-based guidelines for preventing
(Bagshawe et al 1978). The categories included HCAIs (Pratt et al 2007) – which are
enteric, airborne and parenterally spread infections. available at www.epic.tvu.ac.uk – and
revise the precautions that should be
Time out 1 taken with all patients in relation to hand
hygiene, personal protective clothing and
Consider the advantages and sharps safety.
disadvantages of standard
categories of isolation. From the guidelines you will see that hand hygiene
is at the vanguard of all infection prevention
When standard categories of isolation are used, strategies (Gould et al 2007). Disposable gloves
the same set of ‘rules’ are implemented for every and disposable aprons are recommended for close
patient with an infection in that category; it is not patient contacts when the hands and clothing might
necessary to have detailed knowledge become contaminated. Blood and body fluids
should always be regarded as a potential source of
FIGURE 1 infection. Sharps are a possible source of
Five principles of infection control contamination and the guidelines for safe sharps
handling and disposal should be adhered to at all
times.
Additional isolation precautions are only
Isolation of Decontamination
patients and of items required when there is a special infection risk. The
barrier precautions and equipment extra precautions to be used with specific
Decontamination Principles Prudent use of infections are outlined in local policies for patient
isolation. All NHS hospitals have their own
isolation policies, which their infection control
of infection teams are responsible for developing and updating
of environment antibiotics
control in line with official evidence-based guidelines (Box
Handwashing 1).

The chain of infection


Understanding the chain of infection is essential
before implementing isolation precautions for
48 february 4 :: vol 23 no 22 :: 2009
NURSING STANDARD
specific pathogens (agents able to cause disease). Malaria is a common cause of PUO in people
Before reading further check your understanding arriving from overseas. Malaria is not transmissible
by completing Time out 3. from one person to another, so once a diagnosis has
been confirmed, isolation precautions are no longer
Time out 3 necessary. Some other tropical infections are
thought to be extremely contagious and carry a high
Draw a diagram to illustrate the chain mortality rate (Box 2). Stringent isolation
of infection. Use the diagram to precautions are therefore required for returning
explain to junior colleagues the chain travellers with PUOs until diagnosis is established.
of infection for three different types All health workers need to recognise the
of pathogenic microorganism that implications
you might encounter in your of PUOs for other patients and for staff
clinical setting. Useful textbooks to help include regardless of the clinical setting in which they
Wilson (2006) and Gould and Brooker (2008). are employed.
Most will never encounter a patient with viral
Your diagram should indicate that to cause haemorrhagic fever, but the risk should never be
infection, microorganisms must first gain overlooked, especially in large cities with links to
access to a susceptible host, move to a part of major international airports (Box 3). Special
the body where they can grow, multiply and arrangements should be made to transport such
reproduce, and release new pathogens ready patients straight to a centre where expert care can
to cause infection once more. be provided. They should not be allowed to come
The following information should be into contact with the public.
considered when planning isolation Mode of transmission Isolation precautions are
precautions to break the chain of infection effective when the chain of infection has been
caused by a specific microorganism: broken by interrupting the transmission of
microorganisms. Modes of transmission include:
The nature of the causative organism.
Direct contact.
Mode of transmission.
Indirect contact.
Portals of entry into the human host.
Inhalation/droplet.
Possible reservoirs of infection.
Waterborne.
Portals of exit.
Foodborne.
The causative organism Establishing which Sexual activity.
organism is responsible for the infection is an
obvious first step when planning appropriate
BOX 1
infection control precautions. Although there are
times when this information is not readily Evidence-based guidelines for isolation precautions
available. It can take up to five days for bacteria to
All NHS hospitals in the UK have local policies for isolating patients
be cultured and identified in the laboratory and for
developed and updated by the infection control team. Local policies are
technical staff to undertake sensitivity testing for informed by official guidance, which in England comes from the Department
different antibiotics (Kluytmans 2007). Some of Health (DH), the Health Protection Agency and the National Patient
bacteria, notably Mycobacterium tuberculosis, are Safety Agency. In Wales guidance is produced by the Welsh Assembly
difficult to culture and the results can take much Government and in Scotland by Health Protection Scotland and Quality
longer. Occasionally patients present with the signs Improvement Scotland. In Northern Ireland guidance comes from the
and symptoms of infection, but the nature of the Department of Health Social Services and Public Safety.
causative organism is unknown. The research that informs guideline development is frequently
It is prudent to maintain patients with pyrexia of undertaken by bodies such as the Infection Prevention Society
unknown origin (PUO) in isolation until further (formerly the Infection Control Nurses’ Association (ICNA)) and the
information becomes available. Overseas travellers Hospital Infection Society. For example, guidelines to prevent the
frequently arrive in the UK with PUOs. They spread of glycopeptide-resistant enterococci were developed jointly by
should be questioned about the countries they have these two organisations (Cookson et al 2006). Guidelines for the
visited and the extent to which they have ventured control and prevention of meticillin-resistant Staphylococcus aureus
were developed by the ICNA, the Hospital Infection Society and the
away from urban conurbations into rural areas
British Society of Antimicrobial Chemotherapy (Coia et al 2006). The
where they may have encountered tropical
DH also commissions systematic reviews and guideline development
infections, which are often carried by animals or from other agencies, including university departments (Pratt et al
insects and occasionally passed to human hosts. 2007). Professional associations such as the Royal College of Nursing
This information can help to establish diagnosis. also publish guidelines to enable their members to practise safely.

NURSING STANDARD february 4 :: vol 23 no 22 :: 2009 49


learning zone infection control Time out 4
Reflect on the routes most likely
to result in the transmission of
BOX 2 infection in hospital. Which do
you think are most important?
The viral haemorrhagic fevers Check your understanding with
the information provided.
The viral haemorrhagic fevers include Lassa, Marburg and Ebola
fevers, caused by ribonucleic acid viruses, which are endemic in
In healthcare premises microbial spread occurs by
central and western Africa (Winter 2005). The viruses are carried by
direct and indirect contact and, in some cases, by
rodents and monkeys. There is evidence that they can be extremely
virulent. In 1967, seven animal handlers in the German town of
the airborne route. Infection is also occasionally
Marburg died after contact with infected laboratory monkeys imported introduced to healthcare premises in contaminated
from Uganda. Occasional cases are reported in people who have been food, with subsequent person-to-person spread by
in the bush and in health professionals working abroad, and over the contact (Wall et al 1996). The most common mode
years occasional outbreaks have been reported. of transmission is by direct contact, often on the
The early symptoms of infection are often non-specific. Therefore many
hands of health workers. This is the way that most
people familiar with the onset of malaria attribute vague feelings of malaise HCAIs are spread and explains why hand hygiene
to this infection. However, the disease progresses rapidly. There is is emphasised as the single most important way of
haemorrhaging into the internal organs, the appearance of a rash that breaking the chain of infection (Gould et al
bleeds and reduction in blood count progressing to seizures and death. Even
with intensive supportive treatment in western hospitals the mortality rate is 2007), forming an important part of all isolation
high. Death is usually within ten days of infection. precautions (Pratt et al 2007).
The viral haemorrhagic fevers are transmitted by blood and body Outbreaks of foodborne disease have been
fluids and all are highly infectious. As the incubation period is 21 reported in hospitals, although this is less common
days travellers can arrive in the UK apparently healthy, sometimes today than in the past. Between 1992 and 1994,
not developing symptoms until several weeks after they have infectious gastrointestinal disease accounted for
arrived. Cases of viral haemorrhagic fever seen in the UK are 15% of all reported outbreaks of infectious disease
usually reported in cities with good links to major airports. in hospitals. In the majority of cases Salmonella was
the causative organism, and was probably
BOX 3 introduced via contaminated food. The subsequent
cross-infection probably occurred through direct and
Case study
indirect contact, especially in situations where
Boris undertook voluntary service overseas as a nurse in a field hygiene was poor (Wall et al 1996). Most HCAIs
hospital in the border area between Uganda and the Democratic caused by gastrointestinal pathogens have occurred
Republic of Congo. Several of his colleagues developed malaria and where there is a high incidence of faecal soiling,
Boris was familiar with the signs and symptoms of the disease. When such as in paediatric, maternity, mental health and
he returned to the UK for a holiday he developed malaise, fatigue and elderly care units (Joseph and Palmer 1989). The
a high temperature, which he attributed to malaria. He was staying airborne route is not thought to be an important
with his parents in a suburb in west London and his mother route of dissemination for HCAIs, but some of the
telephoned the local general practice where Boris was still registered. classic communicable diseases are spread in this
As soon as she heard that Boris was experiencing pyrexia, the way.
practice nurse recommended that he should go to hospital.
Portals of entry into the human host The
Boris was taken by his parents to the nearest emergency department. By main methods by which microorganisms gain
now he was very ill, but his family was able to provide details of his access to the tissues are shown in Box 4. Many
travels. As soon as this information was provided, plans were made to
pathogens enter by inhalation via the respiratory
move Boris to a hospital offering high-level isolation facilities for patients
tract. This is the route taken by the rhinoviruses
with extremely hazardous infections. Only a few such units exist in the UK
and they are used for patients who have or are suspected of having the
(which cause the common cold) and the
viral haemorrhagic infections (Advisory Committee on Dangerous microorganisms responsible for tuberculosis and
Pathogens 1997). childhood infections, such as measles and mumps.
Ingestion via the mouth into the gastrointestinal
While Boris remained in the emergency department other admissions ceased
tract occurs when food or water is contaminated.
because of the risk of exposing patients to a potentially dangerous pyrexia of
unknown origin (PUO) and staff movements in and out of the unit were
This is the route of entry for Salmonella, Shigella,
prevented. A blood film eventually revealed that Boris had malaria. The Campylobacter and Vibrio (cholera).
implications of sending a patient with a PUO who had recently returned from The urogenital tract is the route taken by
Africa to the emergency department was communicated to the practice in west pathogens causing sexually transmitted infections
London. The potentially serious consequences for the health of everyone who including gonorrhoea (Neisseria gonorrhoeae),
had been in contact with Boris, and the unnecessary distress, inconvenience syphilis (Treponema pallidum) and Trichomonas
and cost that disruption of the busy emergency department had caused, were vaginalis. Urinary pathogens, principally Gram-
highlighted. negative bacilli, gain access

50 february 4 :: vol 23 no 22 :: 2009 NURSING STANDARD


via the urethra, usually following the insertion of Breaking the chain of infection
a catheter. The inoculation of pathogens via the
skin or mucous membranes is possible when a Recently there have been moves to customise
surgical incision is made, during accidental injury isolation precautions according to the specific
by injection or via the mouthparts of an insect. infection the patient has. Precautions such as
Hepatitis B, hepatitis C and the human cleaning the immediate environment, handwashing
immunodeficiency virus are transmitted by and refusing admittance to anyone with
injection. The malarial parasite Plasmodium is transmissible infections, including staff, can
inoculated via the mouthparts of infected minimise the risk of further infection (Wilson
mosquitoes. 2006). Additional precautions that might be
Reservoirs of infection These develop when necessary could include precautions for:
favourable conditions promote the growth and Contact.
reproduction of large numbers of bacteria that are
able to cause HCAIs. Some vegetative Infections spread by respiratory droplets.
microorganisms are capable of surviving for Airborne infections.
prolonged periods in the environment and can be
transferred to nearby equipment and surfaces. For Contact precautions These are taken to prevent
example, enterococci (Gray and George 2000) and the transmission of infections spread by direct
streptococci (Sarangi and Rowsell 1995) have both contact with patients, for example by touching the
caused serious outbreaks linked to environmental skin or lesions, such as wounds (Wilson 2006).
contamination and prolonged survival in the
environment. Clostridium difficile forms spores Time out 5
that survive in the environment for at least six
Design a care plan to prevent the spread of an infection
months and are not destroyed by detergents or
disseminated by the contact route, drawing on the
antiseptics (Department of Health 2005).
information below and using a textbook as necessary
(Wilson 2006, Gould and Brooker 2008). You should take
Reservoirs can develop on the skin of health
into consideration the items that are likely to become
workers or patients, leading to cross-infection. The
heavily contaminated. Your care plan
contribution of environmental reservoirs to cross-
should indicate whether the patient will require a single room and
infection depends on their location. A large
which items of personal protective equipment will be necessary.
reservoir of bacteria in a drain is unlikely to be
significant in the spread of infection under normal
circumstances, because there are few opportunities It is desirable for patients with infections spread by
for transfer to susceptible people. If the reservoir direct contact to be nursed in single rooms because
involves objects that have the potential for contact the surrounding surfaces are likely to become
with patients or health workers, the risks increase. heavily contaminated, especially in the case of
A blocked drain overflowing into a sink where patients with gastrointestinal infections who are
health workers wash their hands is likely to experiencing profuse vomiting, diarrhoea or who
become an important reservoir. are incontinent (Weber and Rutala 1997). If this is
Portals of exit Microorganisms generally leave not possible their movements should be restricted to
the body via the entry route, but there are some the bedside area to reduce the risk of widespread
important exceptions. Bacteria causing contamination and the development of
gastroenteritis gain access via the mouth but environmental reservoirs. Personal protective
escape in the faeces. The so-called faecal-oral equipment should include disposable gloves and
route is the means by which norovirus responsible disposable aprons.
for winter vomiting and C.difficile are spread. Disposable gloves and disposable aprons should
be worn whenever contact with an infected patient
and the near-patient environment is anticipated and
must be discarded before contact with another
BOX 4 patient. Theoretically it is not necessary to put on
Gaining access to the tissues: gloves just to enter an isolation room. In practice,
portals of entry however, it might be wise to do so, as patients
Airborne. frequently ask for help that will involve direct
contact as soon as they see a nurse. Hands must
Ingestion – swallowing. always be washed after gloves have been worn
Inoculation – via skin or mucous membranes. because they sometimes leak, can become
contaminated when they are removed and are
Urogenital tract – sexually
transmitted infections. permeable to viruses (Korniewicz et al 1989).
As with any patient, it is necessary to change
Vertical transmission – mother to infant. gloves between ‘dirty’ and ‘clean’ procedures.

NURSING STANDARD february 4 :: vol 23 no 22 :: 2009 51


procedures, such as endotracheal suction, which
learning zone infection control could increase the risk of exposure to droplet
nuclei. Infections spread by droplet nuclei include:
tuberculosis, measles and varicella (chickenpox).
Nurses’ uniforms become contaminated with Negative pressure ventilated rooms are ideal for
microorganisms, mostly from the environment these patients (Box 5). When they are not
(Wilson et al 2007). The front of the uniform can available, the best alternative is a well-ventilated
become heavily contaminated when dressing single room with the door kept shut.
discharging wounds, but the level of contamination Surgical masks are designed to reduce the risk
can be reduced by wearing a disposable apron of infection from large respiratory droplets during
(Babb et al 1983). Gowns are not recommended for high-risk procedures, for example in the operating
use with infected patients because cotton is room, and when there is a risk of blood and body
permeable to microorganisms, especially when it is fluid splashes. They are not designed to filter
damp (Woodhead et al 2002). There is little minute droplet nuclei and so do not offer any
evidence that outside high-risk environments, such special advantage when patients are isolated in
as burns units and operating theatres, pathogens well-ventilated rooms (Fennelly and Nardell
contaminating uniforms pose a risk to other patients 1998). If there is a risk from patients with
(Wilson et al 2007). Respiratory droplets tuberculosis or other airborne pathogens, filter
Infectious airborne particles are released as droplets masks are recommended, although at present
when individuals exhale forcefully, sneeze or studies to evaluate their effectiveness are lacking
cough. Only the smallest droplets (1-5μm) can (Adal et al 1994). Patients with airborne infections
reach the lower airways. In most cases the droplet should be educated to cover the mouth and nose
dries out and settles onto surfaces, including when coughing and sneezing and to expectorate
clothes, in the immediate environment. The into special disposable containers.
microorganisms they carry are able to survive and
are transferred to other objects, such as door Disposal and decontamination procedures
handles and computer keyboards. They reach new
individuals who handle these objects and are Irrespective of the microorganism or its
transferred to the nose and conjunctivae when the mechanism of spread, care must be taken to
face is touched. Direct and indirect contact with an dispose of clinical waste, excreta and soiled linen
infected individual and the environment is therefore safely to avoid contaminating the rest of the
an important route of spread for many respiratory environment and placing others at risk. Issues
illnesses and hand hygiene plays an important role relating to the disposal of clinical waste and the
in prevention (Leclair et al 1987). treatment of items that have been in close contact
with infected patients frequently cause a great deal
Laboratory experiments have demonstrated that of confusion and concern among health workers.
healthy volunteers are much more likely to develop There is often an assumption that isolation
colds if they have direct contact, for example shake procedures require major departures from usual
hands, with someone who is infected than if they practice, but this is not necessarily the case.
inhale cold viruses (Gwaltney et al 1978). Other
infections spread by a combination of the droplet
and contact route include meningococcal Time out 6
meningitis, mumps and pertussis (whooping
cough). Single rooms are highly desirable for Review the policies that are used routinely in
patients with respiratory infections, but the door can your workplace for handling and disposing
be left open to reduce the sensation of social of clinical waste, excreta, soiled linen,
isolation and they should be allowed to leave the clinical equipment, crockery and cutlery.
room for treatment and investigations. Disposable Then look at the policies recommended for
gloves and disposable aprons should be worn for all use when isolation precautions are being
patient contacts and hands must be washed implemented. Compare the two sets of
afterwards. policies to identify how those routinely used
Airborne infections Those infections disseminated are modified when isolation precautions are
by the airborne route are transmitted by inhaling necessary.
minute droplet nuclei containing the causative
pathogen. The small size of droplet nuclei enables Clinical waste from all patients This should be
them to remain suspended in the air for a long time discarded into yellow bags, regardless of whether
after they have escaped. A single room is essential for isolation precautions are being implemented.
patients with airborne infections and the door should Workplace policies should be adhered to. There is no
be kept shut. Disposable gloves and disposable aprons need for special labelling or for double-bagging
are required when undertaking because there is no evidence that
52 february 4 :: vol 23 no 22 :: 2009 NURSING STANDARD
BOX 5 heavily contaminated and, unless disposable or
Negative pressure ventilation reserved for use only by that patient, they should
be cleaned thoroughly with detergent after each
The air is extracted from negative pressure ventilation use. Unnecessary equipment should not be taken
rooms through outlets by special filters so that it flows into isolation rooms or the immediate bed space of
out of the building, taking suspended infected droplets patients with infections to avoid clutter and
with it. These are diluted in the much higher volume
wasteful use of resources.
of air outside, so they cease to represent a threat. Air
Crockery and cutlery This can be processed in
is drawn back into the isolation room from
surrounding rooms because of the negative pressure
the usual way, ideally in a dishwasher with a rinse
gradient set up. For the system to be effective, air temperature of 80°C (Barrie 1996). These items are
must be drawn out of the isolation room faster than not likely to become heavily contaminated with
the rate at which it flows in and the door and windows pathogens and do not provide a hospitable surface
must be kept shut (Hoffman et al 2004). for bacteria to survive and multiply. Cleaning
Until recently it was thought that
the environment played little role in the
the surfaces of plastic bags become contaminated
transmission of infection (Wilson 2006). While this
with pathogens or support their growth and
is probably true of the microorganisms responsible
multiplication (Maki et al 1986).
for tuberculosis and the other classic communicable
Excreta This should be treated as potentially
diseases that require human hosts for growth and
infectious. Bedpans and urinals should be taken
multiplication, there is increasing evidence that the
straight to the sluice by a health worker wearing
bacteria responsible for HCAIs are capable of
gloves and a disposable apron, and placed into
surviving outside the human host, and can be
the bedpan washer or macerator at once.
transferred to new patients from environmental
The contents enter the sewage system, which is full
sources.
of potential pathogens anyway: disinfection of the
As mentioned previously, clostridia and
bedpan washer or macerator is not required.
enterococci survive well in environmental
Personal protective clothing should then be
reservoirs and can be difficult to eradicate. It
discarded into a yellow plastic bag and hands
appears that thorough, regular cleaning can
should be washed. Ideally, patients with infections
contribute to the control of outbreaks caused by the
spread by the faecal-oral route should be admitted
bacteria responsible for HCAIs (Rampling et al
to rooms with en suite facilities or have a commode
2001). Some viruses, notably hepatitis B, can
reserved for their sole use. Laundry The
survive in dried blood and body fluids on surfaces
procedure for dealing with soiled linen taken from
for up to one week (Bond et al 1983).
infectious patients is different from usual practice
Maintaining a clean, dust-free environment and
because laundry workers sort linen by hand before
dealing with spillages of blood and body fluids is
it is washed. To avoid the risk of exposure to
important at all times, not just when patients are
infection, bed clothes from patients with infectious
being isolated. Disposable cloths should be used
conditions should be placed in special water soluble
for cleaning, and separate mops and buckets are
bags with water soluble stitching. This bag is
required for the rooms and bed areas surrounding
placed inside a red outer bag, which is removed by
infectious patients. Liaison between nursing and
the laundry worker. The inner bag will split open
cleaning staff is necessary to achieve acceptable
once it contacts the hot water. The microorganisms
levels of cleanliness and to avoid overlooking
are removed by the diluting action of the washing
items that should be decontaminated when the
and rinsing cycles, and destroyed by the high
patient is no longer infectious or is discharged
temperature of the water and the action of the
(Stacey et al 1998, Karas et al 2002).
detergent (Wilson et al 2007). Temperatures of at
least 71°C must be reached during the wash cycle
Staff and visitors Good communication is
for all linen (NHS Executive 1995).
necessary with all visitors and staff, including
cleaners. It is not necessary for everyone to be
Equipment Traditionally it was thought that
informed about the precise nature of the infection:
clinical equipment, such as stethoscopes and
divulging this information would be a breach of
sphygmomanometer cuffs, that is in contact with patient confidentiality. Everyone who is likely to
infectious patients were not likely to pose an have contact with the patient or their environment,
infection risk. There is mounting evidence that however, is entitled to know how to reduce the
healthcare equipment can transfer nosocomial risks of infection to themselves and should be
pathogens. Disinfection with 70% alcohol is aware of the actions they must take to prevent
recommended if equipment has been used for a spreading it to others.
patient with an HCAI (Schabrun and Chipchase Special accommodation There is a division
2006). Items in immediate contact with the patient of opinion about the need for special
or close patient environment can become
accommodation for patients requiring isolation
NURSING STANDARD february 4 :: vol 23 no 22 :: 2009 53
a source of anxiety and depression (Gammon 1998,
learning zone infection control Lewis et al 1999, Rees et al 2000). These studies
are all small scale with data collection restricted to
a few clinical areas. The most recent research
precautions. Some authorities argue that, as most evidence from the US indicates that, although
infections encountered on healthcare premises are patients with HCAIs nursed in isolation are poorly
spread by contact, careful hand hygiene and contact informed about the need for segregation, they are
precautions should be sufficient without the need not less satisfied with their care than other patients
for single rooms except where heavy environmental and perceive that isolation has a protective effect by
contamination is likely (Wilson 2006). reducing the risks of contracting infection
Those in favour of segregation argue that the additional to the one they already have (Gasink et
much more stringent use of single rooms in the al 2008). Further work needs to be undertaken in
Netherlands helps to account for their lower rates the UK. Public awareness of HCAIs is considerable
of MRSA and HCAIs generally (Doherty et al and it is possible that patients now feel more
2007). In the UK, national guidelines to prevent the positively about segregation.
spread of MRSA (Coia et al 2006) and GRE
(Cookson et al 2006) are much less prescriptive
Conclusion
than in many other countries, and this situation,
coupled with a shortage of suitable single rooms The need to segregate infectious people is deeply
and the many conflicting demands on their use embedded in the human psyche. For many years
(Wigglesworth and Wilcox 2006), might be draconian measures were taken when a patient
contributing to our difficulties controlling HCAIs. presented with one of the classic communicable
Proponents of single room accommodation diseases, ranging from incarceration in a special
argue that they at least reduce the number of fever hospital to strict barrier nursing with the door
contacts with staff and emphasise the importance of kept shut at all times. A more enlightened view is
adhering to infection control precautions. The taken today in line with the use of precautions
Healthcare Commission reports into the outbreaks specific to the infection and each patient’s needs.
of C. difficile at NHS trusts in Buckinghamshire Few, if any, of the microorganisms responsible for
and Kent (Healthcare Commission 2006, 2007) classic communicable diseases survive well outside
assumed that physical segregation represented best the human host and there is little evidence of
practice and criticised both trusts for their failure to infection from the environment and from personal
move patients to single rooms and their tardiness in and clinical equipment.
setting up dedicated cohort wards once the
outbreak was recognised. It could reasonably be The situation with HCAIs is different. Many of
argued that the use of isolation facilities for patients the microorganisms responsible for HCAIs survive
with known HCAIs can help to reassure the public well in the environment, set up reservoirs outside
that everything possible is being done to contain the human host and can be transferred to new
the spread of infection, especially when outbreaks patients when the hands of health workers become
occur. contaminated and on items of clinical equipment
Impact on patients When isolation precautions are that enter the near-patient environment. These
implemented patient choice is not a consideration. infections pose an enormous risk to patient safety
Individuals’ wishes are not usually taken into account and are a source of concern to health workers,
when they are moved to a single room for this patients and the public. Theoretically, hand hygiene
purpose, or to a special isolation ward. Early studies and contact precautions should be sufficient to
indicated that patients nursed on dedicated isolation control the spread of HCAIs disseminated by the
wards could be disadvantaged through lack of nursing contact route, but the number of cases remains high
expertise specific to their condition, and might be in the UK compared to other countries, especially
overlooked during medical rounds (Bagshawe et al those where isolation rooms are used as a matter of
1978). course. The use of segregation to reduce the risks
More recent research in the United States (US) of HCAI especially during outbreaks merits more
shows that patients with MRSA nursed in isolation research and greater debate NS
are twice as likely as matched controls on general
wards to experience adverse events during hospital
stay, more likely to make formal complaints about Time out 7
their care, more likely to be overlooked during
Now that you have completed the
medical rounds and to experience omissions in
article you might like to write a
nursing care, such as the monitoring of vital signs
practice profile. Guidelines to help
(Stelfox et al 2003).
you are on page 60.
Research in the UK suggests that enforced
segregation can be distressing, stigmatising and
NURSING STANDARD
54 february 4 :: vol 23 no 22 :: 2009
and source isolation on coping Butz A, Larson E (1989) Integrity of Agents in Healthcare Settings 2007.
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